Wellcare No Premium Open (PPO)
Wellcare No Premium Open (PPO) H9976-002 Plan Details
Wellcare No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H9976-002.
$0.00
Monthly Premium
Wellcare No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H9976-002.
Wellcare No Premium Open (PPO) H9976-002 Plan Details
Wellcare No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H9976-002.
$0.00
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5000 Out-of-Network: 10000 |
| Initial Coverage Limit | $4430 |
| Catastrophic Coverage Limit | $7,050 |
| Primary Care Doctor Visit | $0 copay Out-of-Network 40% |
| Specialty Doctor Visit | $35 Out-of-Network 40% |
| Inpatient Hospital Care | $350 copay per day for days 1-5 and a $0 copay per day for days 6-90 Out-of-Network $500 copay per day for days 1-7 and a $0 copay per day for days 8-90 |
| Urgent Care | $40 Out-of-Network $40 |
| Emergency Room Visit | $90 Out-of-Network $90 |
| Ambulance Transportation | $275 Out-of-Network $275 |
Health Care Services and Medical Supplies
Wellcare No Premium Open (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | Medicare Covered Chiropractic Services: $0 per visit. $0 / 12 visits every year in addition to Medicare covered. Out-of-Network Medicare Covered Chiropractic Services: 40% per visit. 40% / 12 visits every year in addition to Medicare covered. |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | Diabetes Supplies: $0 / Diabetes Self-Management Training: $0 / Diabetic Therapeutic Shoes or Inserts: 20% Out-of-Network Diabetes Supplies: 20% / Diabetes Self-Management Training: $0 / Diabetic Therapeutic Shoes or Inserts: 40% |
| Durable Medical Eqipment (DME) | 20% Out-of-Network 40% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | X-Ray Services: $0 / Lab Services: $0. $0 for COVID-related testing. For other services, please refer to the Evidence of Coverage for more information. Out-of-Network X-Ray Services: 40% / Lab Services: 40%. $0 for COVID-related testing. For other services, please refer to the Evidence of Coverage for more information. |
| Home Health Care | $0 copay Out-of-Network 35% |
| Mental Health Inpatient Care | $350 copay per day for days 1-5 and a $0 copay per day for days 6-90 Out-of-Network $500 copay per day for days 1-7 and a $0 copay per day for days 8-90 |
| Mental Health Outpatient Care | $40 for individual or group Out-of-Network 40% for individual or group |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $300.00 to $350.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $90.00 to $350.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $200.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% |
| Outpatient Substance Abuse Care | $40 for individual or group Out-of-Network 40% for individual or group |
| Over-the-counter (OTC) Items | $60 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter. Out-of-Network $60 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter. |
| Podiatry Services | Medicare Covered Podiatry Services: $35 Out-of-Network Medicare Covered Podiatry Services: 40% |
| Skilled Nursing Facility Care | $0 copay per day for days 1-20 and a $188 copay per day for days 21-100 Out-of-Network 20% of the total cost for days 1-100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | The dental benefits on this plan include coverage of preventive and comprehensive services up to $1000, including but not limited to cleanings, x-ray(s), oral exams, fluoride treatments, fillings, dentures or a bridge or a crown and a root canal with a $0 member co-pay. Out-of-Network The dental benefits on this plan include coverage of preventive and comprehensive services up to $1000, including but not limited to cleanings, x-ray(s), oral exams, fluoride treatments, fillings, dentures or a bridge or a crown and a root canal with a 50% member cost-share. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | The vision benefits on this plan cover routine eye exams and up to $100 for unlimited contacts, glasses, lenses, and/or frames per year Out-of-Network The vision benefits on this plan cover routine eye exams and up to $100 with a 40% coinsurance for all services and eyewear received OON, for unlimited contacts, glasses, lenses, and/or frames per year |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | The hearing benefits on this plan include, but are not limited to, an annual exam, hearing aid fitting and evaluation, and up to $1000 a year towards hearing aids A maximum of one hearing aid per ear will apply Out-of-Network The hearing benefits on this plan include, but are not limited to, an annual exam, hearing aid fitting and evaluation with a 40% coinsurance OON, and up to $1000 a year towards hearing aids A maximum of one hearing aid per ear will apply |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | Most services offered at $0 cost share, please refer to your Evidence of Coverage for more information. Out-of-Network Most services offered at $0 cost share, please refer to your Evidence of Coverage for more information. |
